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Eibl T, Schrey M, Rossmann J, Liebert A, Ritter L, Lange R, Steiner HH, Schebesch KM. Resection of meningiomas located in motor eloquent areas - comparative analysis of navigated transcranial magnetic stimulation and conventional neuronavigation. Neurol Res 2024:1-7. [PMID: 38953309 DOI: 10.1080/01616412.2024.2370731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 06/17/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Navigated transcranial magnetic stimulation (nTMS) has been established as a preoperative diagnostic procedure in glioma surgery, increasing the extent of resection and preserving functional outcome. nTMS motor mapping for the resection of motor eloquent meningiomas has not been evaluated in a comparative analysis, yet. METHODS We conducted a retrospective matched-pair analysis for tumor location and size in meningioma patients with tumors located over or close to the primary motor cortex. Half of the study population received nTMS motor mapping preoperatively (nTMS-group). The primary endpoint were permanent surgery-related motor deficits. Additional factors associated with new motor deficits were evaluated apart from nTMS. RESULTS 62 patients (mean age 62 ± 15.8 years) were evaluated. 31 patients received preoperative nTMS motor mapping. In this group, motor thresholds (rMT) corresponded with tumor location and preoperative motor status, but could not predict motor outcome. No patient with preoperative intact motor function had a surgery-related permanent deficit in the nTMS group whereas four patients in the non-TMS group with preoperative intact motor status harbored from permanent deficits. 13 patients (21.3%) had a permanent motor deficit postoperatively with no difference between the nTMS and the non-TMS-group. Worsening in motor function was associated with higher patient age (p = 0.01) and contact to the superior sagittal sinus (p = 0.027). CONCLUSION nTMSmotor mapping did not lead to postoperative preservation in motorfunction. nTMS data corresponded well with the preoperative motorstatus and were associated with postoperative permanent deficits if tumors were located over the motor hotspot according to nTMS.
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Affiliation(s)
- Thomas Eibl
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg, Bavaria, Germany
| | - Michael Schrey
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg, Bavaria, Germany
| | - Jakob Rossmann
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg, Bavaria, Germany
| | - Adrian Liebert
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg, Bavaria, Germany
| | - Leonard Ritter
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg, Bavaria, Germany
| | - Rüdiger Lange
- Department of Neurology, Paracelsus Medical University, Nuremberg, Bavaria, Germany
| | - Hans-Herbert Steiner
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg, Bavaria, Germany
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Marchán-López Á, Lora-Tamayo J, de la Calle C, Jiménez Roldán L, Moreno Gómez LM, Sáez de la Fuente I, Chico Fernández M, Lagares A, Lumbreras C, García Reyne A. Impact of a Hospitalist Co-Management Program on Medical Complications and Length of Stay in Neurosurgical Patients. Jt Comm J Qual Patient Saf 2024; 50:318-325. [PMID: 38296750 DOI: 10.1016/j.jcjq.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 01/04/2024] [Accepted: 01/05/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND The impact of co-management on clinical outcomes in neurosurgical patients is uncertain. This study aims to describe the implementation of a hospitalist co-management program in a neurosurgery department and its impact on the incidence of complications, mortality, and length of stay. METHODS The authors used a quasi-experimental study design that compared a historical control period (July-December 2017) to a prospective intervention arm. During the intervention period, patients admitted to a neurosurgery inpatient unit who were older than 65 years, suffered certain conditions, or were admitted from ICUs were included in the co-management program. Two hospitalists joined the surgical staff and intervened in the diagnostic and therapeutical plan of patients, participating in clinical decisions and coordinating patient navigation with neurosurgeons. The incidence of moderate or severe complications measured by the Accordion Severity Grading System, in-hospital mortality, and length of stay of the two cohorts were compared. Multivariate regression was used to adjust for confounders, and the average treatment effect was estimated using inverse probability of treatment weighting. RESULTS The adjusted incidence of moderate or severe complications was lower among co-managed patients (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.39-0.91). Mortality was unchanged (OR 0.83, 95% CI 0.15-4.17). Length of stay was lower in co-managed patients, with a 1.3-day reduction observed after inverse probability of treatment weighting analysis. CONCLUSION Hospitalist co-management was associated with a reduced incidence of complications and length of stay in neurosurgical patients, but there was no difference in in-hospital mortality.
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Kim SH, Choi SH, Moon J, Kim HD, Choi YS. Enhanced Recovery After Surgery for Craniotomies: A Systematic Review and Meta-analysis. J Neurosurg Anesthesiol 2024:00008506-990000000-00107. [PMID: 38651841 DOI: 10.1097/ana.0000000000000967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 03/15/2024] [Indexed: 04/25/2024]
Abstract
The efficacy of the enhanced recovery after surgery (ERAS) protocols in neurosurgery has not yet been established. We performed a systematic review and meta-analysis of randomized controlled trials to compare the effects of ERAS protocols and conventional perioperative care on postoperative outcomes in patients undergoing craniotomy. The primary outcome was postoperative length of hospital stay. Secondary outcomes included postoperative pain visual analog pain scores, incidence of postoperative nausea and vomiting (PONV), postoperative complications, all-cause reoperation, readmission after discharge, and mortality. A literature search up to August 10, 2023, was conducted using PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus databases. Five studies, including 871 patients, were identified for inclusion in this review. Compared with conventional perioperative care, ERAS protocols reduced the length of postoperative hospital stay (difference of medians, -1.52 days; 95% CI: -2.55 to -0.49); there was high heterogeneity across studies (I2, 74%). ERAS protocols were also associated with a lower risk of PONV (relative risk, 0.79; 95% CI: 0.69-0.90; I2, 99%) and postoperative pain with a visual analog scale score ≥4 at postoperative day 1 (relative risk, 0.37; 95% CI: 0.28-0.49; I2, 14%). Other outcomes, including postoperative complications, did not differ between ERAS and conventional care groups. ERAS protocols may be superior to conventional perioperative care in craniotomy patients in terms of lower length of hospital stay, lower incidence of PONV, and improved postoperative pain scores. Further randomized trials are required to identify the impact of ERAS protocols on the quality of recovery after craniotomy.
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Affiliation(s)
- Seung Hyun Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine
| | - Seung Ho Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine
| | - Jisu Moon
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Korea
| | - Hae Dong Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine
| | - Yong Seon Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine
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Schipmann S, Sletvold TP, Wollertsen Y, Schwake M, Raknes IC, Miletić H, Mahesparan R. Quality indicators and early adverse in surgery for atypical meningiomas: A 16-year single centre study and systematic review of the literature. BRAIN & SPINE 2023; 3:101739. [PMID: 37383433 PMCID: PMC10293231 DOI: 10.1016/j.bas.2023.101739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/22/2023] [Accepted: 04/03/2023] [Indexed: 06/30/2023]
Abstract
Introduction Atypical meningiomas represent approximately 20% of all intracranial meningiomas and are characterized by distinct histopathological criteria and an increased risk of postoperative recurrence. Recently, quality indicators have been introduced to monitor quality of the delivered care. Research question Which quality indicators/outcome measures are being applied in patients being operated for atypical meningiomas? What are risk factors associated with poor outcome? How is the surgical outcome and which quality indicators are reported in the literature? Material and methods The primary outcomes of interest were 30-days readmission-, 30-day reoperation-, 30-day mortality-, 30-day nosocomial infection- and the 30-day surgical site infection (SSI) rate, CSF-leakage, new neurological deficit, medical complications, and lengths of stay. The secondary aim was the identification of prognostic factors for the mentioned primary outcomes. A systematic review of the literature was performed screening studies for the mentioned outcomes. Results We included 52 patients. 30-days outcomes in terms of unplanned reoperation were 0%, unplanned readmission 7.7%, mortality 0%, nosocomial infection 17.3%, and SSI 0%. Any adverse event occurred in 30.8%. Preoperative C-reactive protein over 5 mg/l was independent factor for the occurrence of any postoperative adverse event (OR: 17.2, p = 0.003). A total of 22 studies were included into the review. Discussion and conclusion The 30-days outcomes at our department were comparable with reported outcomes in the literature. Currently applied quality indicators are helpful in determining the postoperative outcome but mainly report the indirect outcome after surgery and are influenced of patient, tumor and treatment related factors. Risk adjustment is vital.
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Affiliation(s)
- Stephanie Schipmann
- Department of Neurosurgery, Haukeland University Hospital, Jonas Lies veg 65, 5021, Bergen, Norway
- Department of Neurorsugery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Truls P. Sletvold
- Department of Clinical Medicine, University of Bergen, Jonas Lies veg 87, 5021, Bergen, Norway
| | - Yvonne Wollertsen
- Department of Neurosurgery, Haukeland University Hospital, Jonas Lies veg 65, 5021, Bergen, Norway
| | - Michael Schwake
- Department of Neurorsugery, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany
| | - Ingrid Cecilie Raknes
- Department of Neurosurgery, Haukeland University Hospital, Jonas Lies veg 65, 5021, Bergen, Norway
| | - Hrvoje Miletić
- Department of Pathology, Haukeland University Hospital, Jonas Lies veg 65, 5021, Bergen, Norway
- Department of Biomedicine, University of Bergen, Jonas Lies veg 91, 5009, Bergen, Norway
| | - Rupavathana Mahesparan
- Department of Neurosurgery, Haukeland University Hospital, Jonas Lies veg 65, 5021, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Jonas Lies veg 87, 5021, Bergen, Norway
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Lin Y, Li C, Wang W, Li J, Huang C, Zheng X, Liu Z, Song X, Chen Y, Gao J, Wu J, Wu J, Tu Z, Lai L, Li XJ, Li S, Yan S. Intravenous AAV9 administration results in safe and widespread distribution of transgene in the brain of mini-pig. Front Cell Dev Biol 2023; 10:1115348. [PMID: 36762127 PMCID: PMC9902950 DOI: 10.3389/fcell.2022.1115348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 12/13/2022] [Indexed: 01/26/2023] Open
Abstract
Animal models are important for understanding the pathogenesis of human diseases and for developing and testing new drugs. Pigs have been widely used in the research on the cardiovascular, skin barrier, gastrointestinal, and central nervous systems as well as organ transplantation. Recently, pigs also become an attractive large animal model for the study of neurodegenerative diseases because their brains are very similar to human brains in terms of mass, gully pattern, vascularization, and the proportions of the gray and white matters. Although adeno-associated virus type 9 (AAV9) has been widely used to deliver transgenes in the brain, its utilization in large animal models remains to be fully characterized. Here, we report that intravenous injection of AAV9-GFP can lead to widespread expression of transgene in various organs in the pig. Importantly, GFP was highly expressed in various brain regions, especially the striatum, cortex, cerebellum, hippocampus, without detectable inflammatory responses. These results suggest that intravenous AAV9 administration can be used to establish large animal models of neurodegenerative diseases caused by gene mutations and to treat these animal models as well.
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Affiliation(s)
- Yingqi Lin
- Guangdong Key Laboratory of Non-human Primate Research, Guangdong-Hongkong-Macau Institute of CNS Regeneration, Jinan University, Guangzhou, China
| | - Caijuan Li
- Guangdong Key Laboratory of Non-human Primate Research, Guangdong-Hongkong-Macau Institute of CNS Regeneration, Jinan University, Guangzhou, China
| | - Wei Wang
- Guangdong Key Laboratory of Non-human Primate Research, Guangdong-Hongkong-Macau Institute of CNS Regeneration, Jinan University, Guangzhou, China
| | - Jiawei Li
- Guangdong Key Laboratory of Non-human Primate Research, Guangdong-Hongkong-Macau Institute of CNS Regeneration, Jinan University, Guangzhou, China
| | - Chunhui Huang
- Guangdong Key Laboratory of Non-human Primate Research, Guangdong-Hongkong-Macau Institute of CNS Regeneration, Jinan University, Guangzhou, China
| | - Xiao Zheng
- Guangdong Key Laboratory of Non-human Primate Research, Guangdong-Hongkong-Macau Institute of CNS Regeneration, Jinan University, Guangzhou, China
| | - Zhaoming Liu
- Key Laboratory of Regenerative Biology, South China Institute for Stem Cell, Biology and Regenerative Medicine, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
| | - Xichen Song
- Guangdong Key Laboratory of Non-human Primate Research, Guangdong-Hongkong-Macau Institute of CNS Regeneration, Jinan University, Guangzhou, China
| | - Yizhi Chen
- Guangdong Key Laboratory of Non-human Primate Research, Guangdong-Hongkong-Macau Institute of CNS Regeneration, Jinan University, Guangzhou, China
| | - Jiale Gao
- Guangdong Key Laboratory of Non-human Primate Research, Guangdong-Hongkong-Macau Institute of CNS Regeneration, Jinan University, Guangzhou, China
| | - Jianhao Wu
- Guangdong Key Laboratory of Non-human Primate Research, Guangdong-Hongkong-Macau Institute of CNS Regeneration, Jinan University, Guangzhou, China
| | - Jiaxi Wu
- Guangdong Key Laboratory of Non-human Primate Research, Guangdong-Hongkong-Macau Institute of CNS Regeneration, Jinan University, Guangzhou, China
| | - Zhuchi Tu
- Guangdong Key Laboratory of Non-human Primate Research, Guangdong-Hongkong-Macau Institute of CNS Regeneration, Jinan University, Guangzhou, China
| | - Liangxue Lai
- Key Laboratory of Regenerative Biology, South China Institute for Stem Cell, Biology and Regenerative Medicine, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
| | - Xiao-Jiang Li
- Guangdong Key Laboratory of Non-human Primate Research, Guangdong-Hongkong-Macau Institute of CNS Regeneration, Jinan University, Guangzhou, China
| | - Shihua Li
- Guangdong Key Laboratory of Non-human Primate Research, Guangdong-Hongkong-Macau Institute of CNS Regeneration, Jinan University, Guangzhou, China,*Correspondence: Shihua Li, ; Sen Yan,
| | - Sen Yan
- Guangdong Key Laboratory of Non-human Primate Research, Guangdong-Hongkong-Macau Institute of CNS Regeneration, Jinan University, Guangzhou, China,*Correspondence: Shihua Li, ; Sen Yan,
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Schipmann S, Spille DC, Gallus M, Lohmann S, Schwake M, Warneke N, Suero Molina E, Stummer W, Holling M. Postoperative surveillance in cranial and spinal tumor neurosurgery: when is this warranted? J Neurosurg 2022; 138:1188-1198. [PMID: 36115051 DOI: 10.3171/2022.7.jns22691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/18/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The outbreak of COVID-19 and the sudden increase in the number of patients requiring mechanical ventilation significantly affected the management of neurooncological patients. Hospitals were forced to reallocate already scarce human resources to maximize intensive care unit (ICU) capacities, resulting in a significant postponement of elective procedures for patients with brain and spinal tumors, who traditionally require elective postoperative surveillance on ICU or intermediate care wards. This study aimed to characterize those patients in whom postoperative monitoring is required by analyzing early postoperative complications and associated risk factors. METHODS All patients included in the analysis experienced benign or malignant cerebral or intradural tumors and underwent surgery between September 2017 and May 2019 at University Hospital Münster, Germany. Patient data were generated from a semiautomatic, prospectively designed database. The occurrence of adverse events within 24 hours and 30 days postoperatively-including unplanned reoperation, postoperative hemorrhage, CSF leakage, and pulmonary embolism-was chosen as the primary outcome measure. Furthermore, reasons and risk factors that led to a prolonged stay on the ICU were investigated. By performing multivariable logistic regression modeling, a risk score for early postoperative adverse events was calculated by assigning points based on beta coefficients. RESULTS Eight hundred eleven patients were included in the study. Eleven patients (1.4%) had an early adverse event within 24 hours, which was either an unplanned reoperation (0.9%, n = 7) or a pulmonary embolism (0.5%, n = 4) within 24 hours. To predict the incidence of early postoperative complications, a score was developed including the number of secondary diagnoses, BMI, and incision closure time, termed the SOS score. According to this score, 0.3% of the patients were at low risk, 2.5% at intermediate risk, and 12% at high risk (p < 0.001). CONCLUSIONS Postoperative surveillance in cranial and spinal tumor neurosurgery might only be required in a distinct patient collective. In this study, the authors present a new score allowing efficient prediction of the likelihood of early adverse events in patients undergoing neurooncological procedures, thus helping to stratify the necessity for ICU or intermediate care unit beds. Nevertheless, validation of the score in a multicenter prospective setting is needed.
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Affiliation(s)
- Stephanie Schipmann
- 1Department of Neurosurgery, University Hospital Münster, Germany; and.,2Department of Neurosurgery, Haukeland University Hospital Bergen, Norway
| | | | - Marco Gallus
- 1Department of Neurosurgery, University Hospital Münster, Germany; and
| | - Sebastian Lohmann
- 1Department of Neurosurgery, University Hospital Münster, Germany; and
| | - Michael Schwake
- 1Department of Neurosurgery, University Hospital Münster, Germany; and
| | - Nils Warneke
- 1Department of Neurosurgery, University Hospital Münster, Germany; and
| | - Eric Suero Molina
- 1Department of Neurosurgery, University Hospital Münster, Germany; and
| | - Walter Stummer
- 1Department of Neurosurgery, University Hospital Münster, Germany; and
| | - Markus Holling
- 1Department of Neurosurgery, University Hospital Münster, Germany; and
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Venous thromboembolic and hemorrhagic events after meningioma surgery: A single-center retrospective cohort study of risk factors. PLoS One 2022; 17:e0273189. [PMID: 35972947 PMCID: PMC9380925 DOI: 10.1371/journal.pone.0273189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 08/04/2022] [Indexed: 11/19/2022] Open
Abstract
Microsurgical resection of meningiomas in a majority of cases leads to a favorable outcome. Therefore, severe postoperative adverse events are less acceptable. The main purpose of this study was to investigate the incidence of symptomatic venous thromboembolism (VTE) and hemorrhagic complications in patients after operative treatment of intracranial meningiomas and to identify the risk factors in this patient subgroup. Of 106 patients undergoing elective craniotomy for meningioma overall incidence of symptomatic VTE was noted in 5.7% (six patients). For the risk-factor analysis older age (57.20 ± 11.60 vs. 71.00 ± 0.90 years, p < 0.001), higher body mass index (27.60 ± 4.80 vs. 33.16 ± 0.60 kg/m2, p < 0.001), WHO grade II (3.00% vs. 33.33%, p = 0.02), lower intraoperative blood loss (466.00 ± 383.70 vs. 216.70 ± 68.30 mL, p < 0.001), bedridden status and neurologic deficit (0.00% vs. 33.33%, p = 0.003 and 38.00% vs. 100.00%, p = 0.004) were associated with greater VTE risk. No risk factors for hemorrhagic complications were identified on univariate analysis. In conclusion, the incidence of VTE in meningioma patients is not negligible. Identified risk factors should be taken into account in the decision-making process for chemoprophylaxis when the risk of bleeding decreases.
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Lin M, Min E, Orloff EA, Ding L, Youssef KSR, Hu JS, Giannotta SL, Mack WJ, Attenello FJ. Predictors of readmission after craniotomy for meningioma resection: a nationwide readmission database analysis. Acta Neurochir (Wien) 2020; 162:2637-2646. [PMID: 32779026 DOI: 10.1007/s00701-020-04528-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Meningiomas are the most common benign primary brain tumors. The mainstay of treatment, surgical resection, is often curative. Given the excellent prognosis of these lesions, minimizing perioperative complications is of the utmost importance. With the establishment of the National Readmissions Database (NRD), researchers are now able to identify variables associated with postoperative complications beyond the index admission. OBJECTIVE In this study, we sought to identify the leading causes for non-elective readmission and variables associated with increased likelihood of readmission at 30 and 90 days after discharge following a craniotomy for meningioma resection. METHODS Adult inpatients who underwent craniotomy for meningioma resection between 2010 and 2014 were queried from the NRD. All-cause readmissions following craniotomy at 30 and 90 days were identified, and a multivariable logistic regression model was used to characterize independent risk factors. RESULTS Among 26,034 patients who received craniotomy for meningioma resection, 2825 (10.9%) were readmitted at 30 days and 3436 (16.1%) were readmitted at 90 days. Postoperative wound infection was the most common readmission diagnosis, occurring in 9.32% and 10.2% of 30- and 90-day readmissions respectively. Patient factors associated with increased likelihood of readmission included male gender, greater illness severity, non-routine discharge, index length of hospitalization, and having Medicare or Medicaid insurance. CONCLUSIONS Readmission following craniotomy for meningioma resection occurs at a clinically significant rate. Several patient factors were identified in association with all-cause 30- and 90-day readmissions. Further studies are required to identify means for preventing complications following discharge in these vulnerable patient populations.
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de Almeida CC, Boone MD, Laviv Y, Kasper BS, Chen CC, Kasper EM. The Utility of Routine Intensive Care Admission for Patients Undergoing Intracranial Neurosurgical Procedures: A Systematic Review. Neurocrit Care 2019; 28:35-42. [PMID: 28808901 DOI: 10.1007/s12028-017-0433-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients who have undergone intracranial neurosurgical procedures have traditionally been admitted to an intensive care unit (ICU) for close postoperative neurological observation. The purpose of this study was to systematically review the evidence for routine ICU admission in patients undergoing intracranial neurosurgical procedures and to evaluate the safety of alternative postoperative pathways. METHODS We were interested in identifying studies that examined selected patients who presented for elective, non-emergent intracranial surgery whose postoperative outcomes were compared as a function of ICU versus non-ICU admission. A systematic review was performed in July 2016 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist of the Medline database. The search strategy was created based on the following key words: "craniotomy," "neurosurgical procedure," and "intensive care unit." RESULTS The nine articles that satisfied the inclusion criteria yielded a total of 2227 patients. Of these patients, 879 were observed in a non-ICU setting. The most frequent diagnoses were supratentorial brain tumors, followed by patients with cerebrovascular diseases and infratentorial brain tumors. Three percent (30/879) of the patients originally assigned to floor or intermediate care status were transferred to the ICU. The most frequently observed neurological complications leading to ICU transfer were delayed postoperative neurological recovery, seizures, worsening of neurological deficits, hemiparesis, and cranial nerves deficits. CONCLUSION Our systematic review demonstrates that routine postoperative ICU admission may not benefit carefully selected patients who have undergone elective intracranial neurosurgical procedures. In addition, limiting routine ICU admission may result in significant cost savings.
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Affiliation(s)
- Cesar Cimonari de Almeida
- Department of Surgery, Division of Neurosurgery, Beth Israel Deaconess Medical Center, Lowry Medical Building 3B, 02215, Boston, MA, USA
| | - M Dustin Boone
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - Yosef Laviv
- Department of Surgery, Division of Neurosurgery, Beth Israel Deaconess Medical Center, Lowry Medical Building 3B, 02215, Boston, MA, USA
| | | | - Clark C Chen
- Department of Neurosurgery, University of California San Diego, San Diego, CA, USA
| | - Ekkehard M Kasper
- Department of Surgery, Division of Neurosurgery, Beth Israel Deaconess Medical Center, Lowry Medical Building 3B, 02215, Boston, MA, USA
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Brain Tumor Surgery is Safe in Octogenarians and Nonagenarians: A Single-Surgeon 741 Patient Series. World Neurosurg 2019; 132:e185-e192. [PMID: 31505286 DOI: 10.1016/j.wneu.2019.08.219] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 08/26/2019] [Accepted: 08/28/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Elderly patients with surgically accessible brain tumors are often not offered clinically indicated brain tumor surgery (BTS) because of to assumptions of greater risk for perioperative morbidity and mortality. Because brain tumor incidence is highest in the geriatric population, and because the global population is aging, accurate understanding of BTS risk in elderly patients is critical. We aimed to compare safety of BTS in elderly patients with younger counterparts to better understand the risk-benefit profile of BTS for elderly patients. METHODS Retrospective cohort study of young (20-29 years), senior (60-79 years), and elderly (80+ years) patients who underwent BTS with a single neurosurgeon. Differences between pre- and postoperative modified Rankin score (ΔmRS), length of hospitalization (LOH), complication rate, and 30-day readmission rates (30DRR) were recorded. RESULTS A total of 741 patients (83 elderly, 570 senior, and 88 young) were identified. No significant difference in preoperative mRS between different age groups, χ2 = 0.269, P = 0.874. Elderly complication rate was 6.0%, not significantly different from young (4.5%, P = 0.667) or senior (7.2%, P = 0.696) complication rate. Elderly LOH was 1.93 ± SD 0.176 days; not significantly different from young (3.01 ± 0.384 days, P = 0.081) or senior (2.47 ± 0.144 days, P = 0.881). Statistical equivalence testing showed with 95% confidence that there was equivalence in ΔmRS among age groups. CONCLUSIONS Elderly patients did not have significantly different ΔmRS, LOH, 30DRR, or complication rates after BTS compared with younger counterparts. Therefore, in healthy patients, advanced age alone should not prevent patients from being offered BTS.
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Shin YS, Lee Y. Associations between smoking and postoperative complications following elective craniotomy. J Neurosurg Sci 2019; 65:642-647. [PMID: 31220912 DOI: 10.23736/s0390-5616.19.04693-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Evidence of postoperative complications associated with smoking has varied. We conducted this study to clarify the relationships between tobacco smoking and postoperative complications following craniotomy. METHODS A retrospective cohort analysis identified 800 patients who underwent cranial surgery with general anesthesia at a medical center with 2,700 beds in Seoul, Korea between January and December 2011. RESULTS Prior smokers (34.8%) and current smokers (35.1%) were hospitalized for at least 11 days longer than never smokers (25.5%) (x2 = 6.74, p = 0.036). There were no statistically significant differences in the incidence of postoperative complications among never smokers (5.2%), prior smokers (9.6%), and current smokers (9.6%). The incidences of postoperative complications among prior smokers (9.6%) and current smokers (9.6%) were similar. Comparisons between never smokers (25.5%) and current smokers (34.9%) showed smokers had longer hospital stays and a higher incidence of complications (x2 = 6.74, p = 0.012). The incidence of major complications (x2 = 5.27, p = 0.024) and overall complications (x2 = 4.84, p = 0.033) were also significantly higher among smokers than never smokers. The impact of smoking status on postoperative complications was not identified. CONCLUSIONS We found significant associations between smoking status and postoperative complications. The incidence of major complications was twice as high among smokers as among never smokers. Therefore, it is recommended to continuously monitor current smokers to prevent postoperative complications after craniotomy.
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Affiliation(s)
- Yong S Shin
- School of Nursing, Hanyang University, Seoul, Korea
| | - Yoonyoung Lee
- Department of Nursing, Sunchon National University, Suncheon, Korea -
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Diffusion-weighted magnetic resonance imaging for detection of postoperative intracranial pyogenic abscesses in neurosurgery. Acta Neurochir (Wien) 2019; 161:985-993. [PMID: 30915573 DOI: 10.1007/s00701-019-03875-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 03/08/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Diffusion-weighted magnetic resonance imaging (MRI-DWI) is the modality of choice for detecting intracranial abscesses; however, it is unclear whether prior brain surgery has an influence on its diagnostic value. Thus, we assessed the robustness of MRI-DWI and determination of an ADC cutoff value for detecting intracranial abscesses in patients who underwent brain surgery. METHODS We retrospectively evaluated 19 patients prior to surgery for postoperative supratentorial parenchymal abscesses by means of MRI-DWI. Forty randomly selected patients with routine postoperative MRI-DWI were used for comparative analyses. Clinical and serum biomarkers (C-reactive protein, interleukin-6, white blood cell count) as well as from results of early postoperative imaging findings (computed tomography and/or MRI scan) were recorded. Additionally, ADC values, T1±gadolinium, and T2/fluid-attenuated inversion recovery sequences were investigated. RESULTS After initial surgery, early postoperative control imaging showed evidence of hemorrhage and/or hemostatic agents within the resection cavity in 10/19 patients of the abscess group and in 16/40 patients of the control group. No postoperative ischemia was detected. Neither hemostatic agents nor blood affected the mean ADC values in both the reference group (blood 2.96 ± 0.22 × 10-3 mm2/s vs. no blood 2.95 ± 0.26 × 10-3 mm2/s, p = 0.076) and in the abscess group (blood 0.87 ± 0.07 × 10-3 mm2/s vs. no blood 0.76 ± 0.06 × 10-3 mm2/s, p = 0.128). The mean ADC value within the resection cavity was significantly lower in the abscess group (1.5 T 0.88 ± 0.41 vs. 2.88 ± 0.20 × 10-3 mm2/s, p < .01; 3.0 T 0.75 ± 0.24 vs. 3.02 ± 0.26 × 10-3 mm2/s, p < 0.01). The optimal ADC cut-off for the differentiation of an abscess from normal postoperative findings was found at 1.87 × 10-3 mm2/s (area-under-the-curve 1.0, sensitivity = 100%, specificity = 100%). Moreover, no differences between the abscess patients and the control group were seen with respect to the analyzed serum biomarkers. CONCLUSION MRI-DWI provides a robust tool to discriminate postoperative abscess formation from normal postoperative changes.
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Khan NR, Moore K, Basma J, Hersh DS, Choudhri AF, Vaughn B, Klimo P. Ischemic stroke following elective craniotomy in children. J Neurosurg Pediatr 2019; 23:355-362. [PMID: 30579265 DOI: 10.3171/2018.10.peds18491] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 10/04/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVE An ischemic stroke following an elective craniotomy in a child is perceived to be a rare event. However, to date there are few papers on this topic. The purpose of this study was to investigate the occurrence of stroke following elective intracranial surgery at a children’s hospital. METHODS The authors performed a retrospective review of all patients who developed a perioperative stroke following an elective craniotomy from 2010 through 2017. Data were collected using an institutional database that contained demographic, medical, radiological, and outcome variables. RESULTS A total of 1591 elective craniotomies were performed at the authors’ institution during the study period. Of these, 28 (1.8%) were followed by a perioperative stroke. Radiographic diagnosis of the infarction occurred at a median of 1.7 days (range 0–9 days) from the time of surgery, and neurological deficits were apparent within 24 hours of surgery in 18 patients (62.5%). Infarcts tended to occur adjacent to tumor resection sites (86% of cases), and in a unilateral (89%), unifocal (93%), and supratentorial (93%) location. Overall, 11 (39.3%) strokes were due to a perforating artery, 10 (35.7%) were due to a large vessel, 4 (14.3%) were venous, and 3 (10.7%) were related to hypoperfusion or embolic causes. Intraoperative MRI (iMRI) was used in 11 of the 28 cases, and 6 (55%) infarcts were not detected, all of which were deep. CONCLUSIONS The incidence of stroke following an elective craniotomy is low, with nearly all cases (86%) occurring after tumor resection. Perforator infarcts were most common but may be missed on iMRI. ABBREVIATIONS ACA = anterior cerebral artery; AChA = anterior choroidal artery; ACS NSQIP-P = American College of Surgeons National Surgical Quality Improvement Program–Pediatric; CVA = cerebrovascular accident; DWI = diffusion weighted imaging; iMRI = intraoperative MRI; MCA = middle cerebral artery; mRS = modified Rankin Scale; PCA = posterior cerebral artery.
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Affiliation(s)
| | | | | | | | - Asim F Choudhri
- Departments of1Neurosurgery and
- 2Radiology, University of Tennessee Health Science Center
| | | | - Paul Klimo
- Departments of1Neurosurgery and
- 3Le Bonheur Children's Hospital; and
- 4Semmes Murphey, Memphis, Tennessee
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Champagne PO, Brunette-Clement T, Bojanowski MW, Moumdjian R, Fournier-Gosselin MP, Bouthillier A, Shedid D. Safety of performing craniotomy in the elderly: The utility of co-morbidity indices. INTERDISCIPLINARY NEUROSURGERY 2018. [DOI: 10.1016/j.inat.2018.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Goel NJ, Mallela AN, Agarwal P, Abdullah KG, Choudhri OA, Kung DK, Lucas TH, Isaac Chen H. Complications Predicting Perioperative Mortality in Patients Undergoing Elective Craniotomy: A Population-Based Study. World Neurosurg 2018; 118:e195-e205. [DOI: 10.1016/j.wneu.2018.06.153] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Revised: 06/18/2018] [Accepted: 06/19/2018] [Indexed: 11/26/2022]
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Henker C, Schmelter C, Piek J. [Complications and monitoring standards after elective craniotomy in Germany]. Anaesthesist 2017; 66:412-421. [PMID: 28289766 DOI: 10.1007/s00101-017-0291-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Revised: 01/24/2017] [Accepted: 02/21/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND The increasing endeavors to make inpatient treatment processes more effective leads to a reduction of the length of stay in hospital and minimization of postoperative monitoring. Therefore, the aim of our study was to determine potential postoperative complications for neurosurgical patients undergoing elective surgery with respect to assessment of the relevance for intensive medical care. Furthermore, our approach was compared with the standard of postoperative care of such patients in Germany. METHODS All 499 patients scheduled for elective craniotomy at our institute from 2010-2013 could be included corresponding to various treatment criteria for vascular diseases, such as aneurysms, arteriovenous malformation (AVM) and cavernous hemangioma as well as supratentorial and infratentorial tumors, transsphenoidally operated pituitary adenomas and stereotactic biopsies. All complications could be collated and categorized according to major and minor complications. Furthermore, a survey was conducted among 155 neurosurgical hospitals and departments with respect to the preferred postoperative monitoring strategy for the named treatment categories. RESULTS The numbers of major complication were in accordance with data from other studies and although minor complications (13.4% in our collective) are rarely recorded in the literature, they do however indicate an adequate postoperative inpatient monitoring. The results of the survey showed a broad preference for intensive care unit monitoring of patients undergoing elective craniotomy in Germany. CONCLUSION The undisputed gold standard of postoperative monitoring of neurosurgical patients undergoing elective surgery is still the intensive care unit. Although more flexible surveillance modalities are available, a cost-driven restructuring of postoperative monitoring and in particular reduction of the length of stay in hospital must be subjected to detailed scrutinization.
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Affiliation(s)
- C Henker
- Klinik für Chirurgie, Abteilung für Neurochirurgie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland.
| | - C Schmelter
- Klinik für Chirurgie, Abteilung für Neurochirurgie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland
| | - J Piek
- Klinik für Chirurgie, Abteilung für Neurochirurgie, Universitätsmedizin Rostock, Schillingallee 35, 18057, Rostock, Deutschland
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